When patient William Terry, MD, was randomly selected to participate in a pilot study to receive care at home instead of being admitted to BWH, he didn’t think twice about signing up.
“When it comes down to it, no one wants to be sick and in the hospital,” said Terry, an administrator in the Center for Interdisciplinary Cardiovascular Sciences. “If participating in the pilot meant that I could receive the same level of care that I would get in the hospital in the comfort of my own home, I was absolutely on board.”
For two months last year, David Levine, MD, MA, a physician and researcher in the Division of General Internal Medicine and Primary Care, and co-principal investigator Jeff Schnipper, MD, MPH, piloted “The Home Hospital” project at BWH and BWFH. The pilot sought to compare the cost, quality, safety and experience of hospital-level care at home to traditional hospitalization. Levine received the Brigham Research Institute’s $100,000 BRIght Futures Prize for the project last November, which will enable him to expand the pilot through this year and further study its outcomes.
Twenty-one adult patients participated in Levine’s randomized, controlled trial. The patients, who had to live within 5 miles of the Brigham in order to participate, came to the BWH or BWFH Emergency Department (ED) seeking care for problems including infections, heart failure, asthma exacerbation and chronic obstructive pulmonary disease (COPD). The ED determined that they required admission, but before being admitted, eligible patients could enroll and be randomly selected for either the home hospital or traditional hospital admission.
The home hospital model
At home, patients received visits from home hospital physicians Levine and Kei Ouchi, MD, MPH, and nurses Amy Costa, RN, Janet James, RN, Kathleen Melville, RN, and Peter Murphy, BSN, RN. Patients benefitted from state-of-the-art technology, including a remote vital-sign monitoring device that enabled their doctor or nurse to check their heart rate and other vitals with a skin patch. The team also monitored patient activity and tracked sleep, which allowed the team to test its hypothesis that patients move and sleep more when they are at home. All of the patients were given an electronic tablet that allowed them to directly and confidentially communicate with their team via phone, text and video at any time of day.
Levine and his team performed safety walk checks of each home they visited to optimize the home environment. They also performed medication reconciliation checks and made sure patients felt comfortable using the tablet. Once a patient’s health improved, he or she would be considered discharged from the Brigham. The pilot used the same clinical criteria for discharging that BWH uses for inpatients, including checking a patient’s clinical stability, ability to eat and drink, and pain control. Research assistants Jeff Medoff, Apexa Patel and Natasha Thiagalingam were also part of the pilot.
“For over a decade, the home hospital model has been practiced in Europe and Australia, where patients have experienced the same level of safety and quality compared to traditional hospital stays, in addition to improved patient experience and reduced costs,” Levine said. “But this model has rarely been tried or rigorously tested in the U.S.”
While Levine said that some procedures will always need to be performed in a hospital setting, there are some cases where home may be the best place for patients to receive care, monitoring and treatment. Levine says the pilot was a first step in testing this model.
“We believe receiving care at home puts the patient first, improves patient experience and reduces costs,” Levine said. “Patients can sleep in their own bed, eat their own food and spend more time with family and friends. For many conditions, a home hospital will transform our concept of safe, high-quality and cost-effective care.”
Data collected from the pilot shows that home hospital care lowered costs, improved patient experience, maintained quality and safety, and improved sleep and activity.
“Patients were also in an ideal setting to receive education and coaching from their care team, empowering them to take care of themselves once their health improved,” said Levine.
What happens at home stays at home
After being evaluated in the ED, Terry’s care team decided he would need to be admitted to the hospital. Before being admitted, the home hospital team approached Terry and obtained his consent to participate. To Terry’s delight, he was selected for the home hospital group. Soon after, Levine and Terry drove together to Terry’s home, and Levine helped him set up his medical supplies and medications.
“The pilot converts care from a one-size-fits-all model to a more personalized approach,” said Terry, who believes he was able to recover more quickly at home. “It was a terrific project to be a part of, and I hope it is expanded in the future. It’s a big step forward in terms of the delivery of patient care.”
Costa, of Partners HealthCare at Home, said she enjoyed participating and seeing the pilot built from the ground up.
“Today, it is very rare to see a doctor make a house call,” Costa said. “All of the patients I cared for during the pilot were grateful for Dr. Levine’s follow-through in their care at home. It was nice to work with a group of energetic and engaged people who wanted to make every part of the pilot a success.”
Murphy, also of Partners HealthCare at Home, agreed and said the pilot reinforced the fact that patients can still be supported by their care team from their own homes.
“When you’re at home with a patient, you are entirely focused on them in their own home environment,” Murphy said. “The whole person is right in front of you. You are able to help identify what they need in order for them to heal at home, while also encouraging them to be independent. I feel very fortunate that I was able to contribute to the advancement of this bright idea.”
Looking down the road
Levine plans to re-launch the project this spring. This time around, they will be accepting a broader range of patients with different conditions. In addition, the project will be better integrated with Partners eCare, BWH’s Epic-based electronic health record system.
Another part of the project that Levine is excited about is the addition of community health workers and medical residents who will also be caring for patients.
“We want to make this project a teaching service as well – a place to train new physicians about a different type of patient care,” Levine said. “It’s critical that residents are exposed to several models of care early in their careers.”
Levine’s ultimate goal is to see the project become a formal clinical program at the Brigham. In the future, he hopes to partner with oncology colleagues and enroll patients with cancer.
“It has been an enormous privilege to work on this project with forward-thinking colleagues,” Levine said. “It impacts every part of the hospital, from the Emergency Department to billing to Radiology, and it has allowed us to push the boundaries of how we care for patients.”